“In the nineteenth century health was transformed by clear, clean water. In the twenty-first century, health will be transformed by clean clear knowledge”
– Sir Muir Gray
”..the transformation of healthcare by the involvement of patients, the mobilisation of knowledge and the appropriate use of technology.”
– Sir Muir Gray
40 years ago those born Alaska Native, had on average 2 diarrheal admissions to hospital in the first year of life. Since that time, clean water and sanitation have made a huge difference across Alaska, but not for all. Currently, 1400 Alaska natives (approximately 1.3% of the Alaska Native population) in rural villages still have no running water and for sanitation, empty their “honey buckets” daily (Parents, in future “you don’t know how good you have it” discussion with your kids, you may want to let them know that this chore is for children – more often then not, walking across icy and slippery ground!).
In the Alaska Native healthcare system we see all the elements of transformation predicted by Sir Muir. The first, big steps in health came with clear clean water (and as outlined above, there is still more to do on that front).
More recently transformation has come from the active engagement and partnership of people/ patients/ families and the Native Health system – of the people, for the people – mobilising both human capital and knowledge of what works best for local communities.
Excitingly, we are now seeing a further wave of innovation through the use of technology in the form of telemedicine between the towns and isolated rural communities.
We were fortunate to see a simulation suite at the Alaska Native Medical Centre in Anchorage, with many similarities to our own. It was interesting to see the simple rules, vision and mission, as well as the virtual dissection table.
Health aides- for general healthcare, dental care and behavioural care
Half of all Alaska Native patient care is sought and provided at the village level. This is understandable when many villages have no road access (for example, the State capital Juneau is only accessible by boat), 700-800 inches of snow a year, incredibly brutal work conditions (fishing, hunting…think “worlds most deadliest catch”!) with many work trauma related injuries in addition to more general healthcare issues. Like many parts of New Zealand, access to GPs in these communities are limited. The Alaska Health system has evolved over the last 60 years to provide levels of care that are adaptive, local and effective for many of the presenting health issues. Of note, health aides in villages provide services to everyone needing health care, and not only Alaska Natives.
This has been made possible by the use of over 500 health aides, (including the adoption of the New Zealand dental health aide program, with initial training provided in New Zealand). The evolution of the health aide program began with the need to respond in local communities to the Alaskan tuberculosis epidemic of the late 1940’s. Later in the 1950’s, Dr Walter Johnson, identified that people within their own villages can provide health care. To build on this capability, the health aide program was developed.
As part of the principle of self determination, health aides are selected by communities (usually from within that community), attend training and work in village clinics. Health aides are the “eyes, ears and hands” of the health system as Dr Johnson described them. They are trained, they are provided with cleverly constructed guide books detailing a response to most common situations. There is a very clear and rigorous supervision process, with telephone and telemedicine contact between the health aide and the doctor based in a town, often many miles away. As Sir Muir predicted, 21 century care is coming down the mobile phone!
First class of Community Health Aide graduates and their instructor, 1968.
The dental health aides have some important evaluation results.
On a qualitative level, people we spoke to reported that within 10 years of the introduction of the program, they have moved from terrible rates of cavity and caries, to “cavity free kids”, and no longer seeing children with dentures.
What’s the learning?
The Alaska Native healthcare system is transformed from its early days of more Westernised care. At the heart of their huge, sustained changes, are:
- Self determination – health care for Alaska Natives by Alaska Native controlled organisations
- A cultural energy and passion for high quality care for indigenous people leadership that understands the involvement of people, knowledge and technology
- Astute political management of a system which includes over 200 tribes sophisticated consensus decision making
- Leadership and improvement training for Alaska natives in a very advanced health sciences campus,
- The injection of additional resources.
If we look at the literature on transformation we see in the Alaskan Native system examples of all the key considerations.
See Canada’s Lead Program
- Demonstrate systems/critical thinking. The leadership group in the system think analytically and conceptually, as a group openly questioning and challenging the status quo, to identify issues, solve problems, and design and implement effective processes across systems and stakeholders.
- Encourage and support innovation. The leaders of the system create a climate of continuous improvement and creativity aimed at systemic change. Within the many tribes there are different models developing, evaluation is encouraged and learning is welcomed.
- Orient themselves strategically to the future. The leadership group are not inward looking, they continually look outwards, welcome visitors, learn from visitors and from the best in the world, allowing them to scan the environment for ideas, best practices, and emerging trends that will shape the system.
- Champion and orchestrate change. The system actively embraces and celebrates changes. We saw clearly that the local tribal needs are sought, debated, and models of care, system processes are changed to improve health service delivery. The leadership of the system seems to relish the change and the experimentation with new models of care.
Confronting the status quo: – so often transformational change is inhibited by the isolation and lack of collaboration between elements of the system. We saw superb examples of collaboration and consensus decision making that brought over 200 tribes together, along with a coordination of healthcare, engineering works, water, transport and many other key elements necessary to improve health across Alaska. We saw multiple individual tribes moving from independence to interdependence, recognising that no transformation is possible in isolation, transformation needs cross sector approach
Gaps in the capability and understanding about how to execute transformative change: As the invited guests of the tribal mega meeting we saw how the wisdom of elder tribal leaders was carefully passed on to more junior members, with no game playing, honest guidance on actions, and the clear commitment to “all being in it for the long haul”. In such a way, the expertise of older members was respected, listened to, and adopted by other around the table…with active mentoring occurring throughout the day.
Improve or transform conundrum. The Alaska Native Tribal consortium recognised that sometimes to transform we have to give up improving the old. It was obviously hard to let go completely of the western system, there was inevitably a degree of dependency. But in taking a big bold leap, towards an entirely Alaskan Native healthcare system, the shift was seismic, step change and radical – allowing space then to build in continuous improvement.
Rewards / risk. Visible change, done at scale, requires bravery, and an acceptance that failure is possible. Such fear often restrains attempts to make significant change. Rewards tend to come from “keeping the boat afloat”, rather than considering if we need a boat, a car or a helicopter. In the Alaskan system we saw brave leadership, well supported by a consensus decision making process, and a belief in both the rights based and needs based Native healthcare system.
Who is the customer? Transformation can be inhibited by a lack of clarity over who is the customer. In the Alaskan syustem we saw a radical and exciting move from the Alaskan Natives being “patients” to being “customer/owners”. The change of a few words hides the magnitude of the change, and the engagement that resulted from this move.
I took away many photos from my visit to the Alaskan Native Healthcare System. I also took away many ideas and powerful words that underpin their transformation:
The power of self determination – of ownership, re prioritise, turn away from status quo, bravery, “loneliness of leaders”, “create space by stopping some things”, “respectfully celebrate and stop”, collaborate, prepare, lead way, share story, persuade others to follow, “the commons”, common ground, system leadership, educate, “identify knowledge and skill gaps”, address them, look for new models of care, new workforce solutions.
I hope that these ideas might help leaders recognise when/how to improve, and when/how to transform